KNOW BEFORE YOU GO!

As if a breast cancer diagnosis isn't enough, now you have decisions to make. What course of treatment will I have? Will I have chemo and radiation or just one or the other? What kind of surgery will I have, if any? If I have surgery, then comes reconstruction. When do I do that? What kind do I have? Well, all these questions and more will enter your mind. The hardest question I had to answer was what kind of reconstruction is best for me? When I was diagnosed, I was only presented with 2 options: implants and TRAM. I didn't like either of those choices after meeting with a plastic surgeon and doing my homework. I wasn't even told there were more options available, if I were interested. So, I set out to find another option, and I was really pleased to find several other options. I have taken information from sites that were helpful to me and hopefully help you get an idea of what you think would be good for you. If you want detailed information, then go to each individual website. This is just to help you get a start because starting from a search engine like Google is simply overwhelming. Here's to knowing before you go….make your best informed decision about what is best for YOU!

DIEP Flap
The DIEP flap employs skin and fatty tissue in the abdomen to restore the breast. The result in the abdomen is much like a tummy tuck in that the abdominal contour is often improved significantly as well. In contrast to the TRAM flap, the DIEP procedure does not sacrifice the muscles of the abdominal wall. This preserves the abdominal strength and avoids the need for implanted mesh.

Because no abdominal muscle is removed, most women recover more quickly from DIEP compared to TRAM and have a lower risk of losing abdominal muscle strength.  There also tends to be less abdominal wall discomfort because your muscle isn't involved.

The other main difference between the DIEP and TRAM procedures is how blood is supplied to the belly tissue once it becomes your new breast. The DIEP is a called a "free" flap because the tissue is completely detached from the belly and then reattached to the chest area. Hooking up the blood vessels from the belly tissue to chest blood vessels is delicate work. Your doctor has to use a microscope during surgery, which is why DIEP is known as microsurgery. The TRAM procedure doesn't detach the belly tissue from the blood vessels in the belly. The belly tissue, still attached to its belly blood supply, is moved up to the chest area. No blood vessel surgery is necessary. Because of the extra time required for the blood vessel microsurgery, DIEP flap surgery takes longer than TRAM flap surgery (about 5 hours to reconstruct one breast and up to 8 hours if you're having both breasts reconstructed).

SGAP Flap

For the thin woman or those with otherwise inadequate tummy tissue the breast may be reconstructed with tissue borrowed from the gluteal area. Skin, fat, and the tiny feeding blood vessels are collected without loss of underlying muscle tissue. The fatty tissue is removed from the excess in the upper hip providing a closure line that is concealed even in the most delicate of undergarments.

IGAP Flap
The IGAP is similar to the SGAP except that fat is collected from the lower hip and buttock.

TRAM Flap
TRAM stands for the transverse rectus abdominis muscle, which is located in the lower abdomen, between the waist and the pubic bone.

TRAM is the most popular of all reconstruction options, especially for a woman with excess belly fat or an abdomen that has been stretched out by pregnancy. You end up with a "tummy tuck" as a fringe benefit of surgery. Also, abdominal tissue feels most like a natural breast to anyone touching you. For you, the new breast will have little, if any, sensation.

The TRAM is not for everyone. It's NOT a good choice for:

• thin women who don't have enough abdominal tissue,
• women who smoke and therefore have blood vessels that are narrow and less flexible, or
• women who have multiple surgical scars on the abdomen (normal Cesarean-section scars are not usually a problem).

An oval section of skin, fat, and latissimus dorsi muscle is detached and slid around through a tunnel under the skin to the breast area. Blood vessels remain attached whenever possible. The tissue is shaped into a natural-looking breast and sewn into place. If blood vessels have been cut, they are reattached by microscopic surgery to blood vessels in the chest area. The procedure takes about two to three hours.

  

In general, latissimus dorsi is only a good option for a woman with small- to medium-sized breasts, because there is so little body fat in this part of the back. An implant (inserted during the same operation) is almost always necessary to create a breast of moderate size.

Breast Implants
Breast implants involve the least amount of surgery of all your reconstruction options. Slim, small-breasted women tend to do best with breast implants, because they often don't have enough excess belly tissue to form a good tissue transplant. Also, it's easy to achieve a smaller breast size with implants. Breast implants only come in three sizes (small, medium, and large) and the largest is a size 12–14. In Hollywood, size 12 or 14 may be "large," but in the real world, it's small potatoes.

Making room with expanders
For most women, the skin that remains after mastectomy must be stretched or expanded to make room for an implant. To stretch the skin, the surgeon inserts a balloon-type device called a tissue expander under the chest muscle. The expander has a port (a metal or plastic plug, valve, or coil). The port allows the surgeon to add increasing amounts of liquid over time (about six months), without extra surgery.

 

Gradually, your skin and soft tissue are stretched to achieve your desired appearance. The tissue is actually stretched a little beyond your desired size, to create a natural droop. If the tissue is stretched too far, it can cause discomfort and occasionally flatten part of your rib cage. Ask your doctor how she or he plans to prevent this from happening.

Final steps
When stretching is done and your other treatments (chemotherapy, radiation, or both) are completed, the expander is usually replaced with a permanent implant. Breast implants are filled with either saline or silicone gel.

Sometimes, a surgeon may use a permanent expander. This device doubles as an expander and an implant. When stretching is completed and the "expander" is filled to the right amount with saline, the port is removed. Voila—you have a breast implant, with no extra surgery.

Scar tissue
Once a breast implant is in place, scar tissue forms all around it, forming what's called a tissue capsule. Most of the time, these tissue capsules are soft-to-firm, and unnoticeable. However, less than 15% of the time, a hard capsule forms that can be painful and distort the breast. In these cases, a surgeon can break up the scar tissue and, if necessary, replace the implant.

If you have radiation therapy to the breast area, the risk of scar tissue and hardening around the breast implant increases to 40–50%.

Massage and exercises may reduce the risk of forming a hard capsule (with or without radiation). You can ask your surgeon to show you how to massage the implant and the area around it, firmly but gently.

Buttock Crease Transfer
The buttocks are another source of "excess" tissue for breast reconstruction. Although this might be the first place some of us think to go looking for extra padding, buttock crease transfer surgery is rarely done because of its complexity and high failure rate. An oval section of skin, fat, and muscle is completely removed from the buttock and transplanted in the breast area. The tissue is shaped into a natural-looking breast and sewn into place. An additional implant may or may not be required underneath your own tissue to create the size of breast you desire. The scar is conveniently concealed in the buttock crease. Buttock crease transfer surgery is technically difficult because blood vessels that keep the tissue alive must be cut and reconnected—with the aid of a microscope—to a new blood supply on the chest. The procedure can take up to twelve hours. If the newly connected blood vessels are damaged, the transferred tissue may not survive. In this case, the transferred tissue must be surgically removed and your medical team must find you another solution.

Resources

Breastcenter.com
Breastcancer.org



HTASR does not endorse any specific procedures or doctors. This is for information purposes only.